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Diving certification level Diving certification level Level 1 / Open water Level 2 Level 3 or more Advanced or more No certification

Upload your DIVING CERTIFICATION CARDS File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png, webp. Max. file size: 1 MB

Do you want to upload your diving certification cards ? Do you want to upload your diving certification cards ? Yes No Don't forget to bring your diving certification cards

Number of dives

Date of the last dive

Insurance to take with the dive centre ? Insurance to take with the dive centre ? Yes No

Do you want to upload your insurance certificate? Do you want to upload your insurance certificate? Yes No

Upload your insurance certificate File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png, webp. Max. file size: 1 MB

Do you want to upload your medical certificate (less than one year old) ? Do you want to upload your medical certificate (less than one year old) ? Yes No Don't forget to bring your medical certificate of less than one year old.

Upload your medical certificate (less than one year old) File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png, webp. Max. file size: 1 MB

First Name

Last Name

Enter the prefix and your phone number

Relationship

Authorisation for pictures Authorisation for pictures Yes No

Do you want to be part of the newsletter? Do you want to be part of the newsletter? Yes No

Date

Signature Signature of the participant (or, if a minor, participant's parent/guardian signature required) - Please press save before you submit the form SaveClear

1- I have had lung/respiratory, heart, blood problems 1- I have had lung/respiratory, heart, blood problems Yes No

Thoracic surgery, heart surgery, heart valve surgery, stenting or pneumothorax (collapsed lung) Thoracic surgery, heart surgery, heart valve surgery, stenting or pneumothorax (collapsed lung) Yes No

Asthma, wheezing, severe allergies, hay fever or congested airways in the past 12 months that limit my physical activity/exercise Asthma, wheezing, severe allergies, hay fever or congested airways in the past 12 months that limit my physical activity/exercise Yes No

A problem or disease affecting my heart such as angina, exertional chest pain, heart failure, immersion pulmonary edema, heart attack or stroke, or I am taking medication for any heart condition A problem or disease affecting my heart such as angina, exertional chest pain, heart failure, immersion pulmonary edema, heart attack or stroke, or I am taking medication for any heart condition Yes No

Recurrent bronchitis and current cough within the last 12 months, or I have been diagnosed with emphysema Recurrent bronchitis and current cough within the last 12 months, or I have been diagnosed with emphysema Yes No

2- I am over 45 years old 2- I am over 45 years old Yes No

I smoke or inhale nicotine by other means I smoke or inhale nicotine by other means Yes No

I have high cholesterol I have high cholesterol Yes No

I have high blood pressure I have high blood pressure Yes No

I had a close relative die suddenly or from heart disease or stroke before age 50, or: I have a family history of heart disease before age 50 (including heart rhythm disorders, coronary artery disease or cardiomyopathy) I had a close relative die suddenly or from heart disease or stroke before age 50, or: I have a family history of heart disease before age 50 (including heart rhythm disorders, coronary artery disease or cardiomyopathy) Yes No

3- I have difficulty making moderate physical efforts (for example, walking 2 km in 15 minutes or swimming 200 meters without resting), or: I have not been able to participate in normal physical activity due to fitness or health reasons for 12 months. 3- I have difficulty making moderate physical efforts (for example, walking 2 km in 15 minutes or swimming 200 meters without resting), or: I have not been able to participate in normal physical activity due to fitness or health reasons for 12 months. Yes No

4- I had problems with my eyes, ears, nasal passages or sinuses. 4- I had problems with my eyes, ears, nasal passages or sinuses. Yes No

Sinus surgery within the last 6 months Sinus surgery within the last 6 months Yes No

Sinus surgery within the last 6 months Sinus surgery within the last 6 months Yes No

Recurrent sinusitis within the last 12 months Recurrent sinusitis within the last 12 months Yes No

Eye surgery within the last 3 months Eye surgery within the last 3 months Yes No

5- I have had surgery in the past 12 months; or: I have chronic problems related to a previous surgery. 5- I have had surgery in the past 12 months; or: I have chronic problems related to a previous surgery. Yes No

6- I have fainted, had migraines, seizures, stroke, major head injury or persistent neurological damage or disease. 6- I have fainted, had migraines, seizures, stroke, major head injury or persistent neurological damage or disease. Yes No

A head injury with loss of consciousness within the last 5 years A head injury with loss of consciousness within the last 5 years Yes No

A persistent neurological injury or disease A persistent neurological injury or disease Yes No

Recurrent migraines in the last 12 months, or: I take medication to prevent them Recurrent migraines in the last 12 months, or: I take medication to prevent them Yes No

Fainting spells, blackouts or fainting spells (total or partial loss of consciousness) within the last 5 years Fainting spells, blackouts or fainting spells (total or partial loss of consciousness) within the last 5 years Yes No

Epilepsy, or seizures, or I take medication to prevent them Epilepsy, or seizures, or I take medication to prevent them Yes No

7- I am currently undergoing treatment (or have required treatment in the past five years) for psychological problems, personality disorders, panic attacks, or drug or alcohol dependency; or, I have been diagnosed with a learning disability. 7- I am currently undergoing treatment (or have required treatment in the past five years) for psychological problems, personality disorders, panic attacks, or drug or alcohol dependency; or, I have been diagnosed with a learning disability. Yes No

Behavioral, mental or psychological problems requiring medical and/or psychiatric treatment Behavioral, mental or psychological problems requiring medical and/or psychiatric treatment Yes No

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication or psychiatric treatment Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication or psychiatric treatment Yes No

A diagnosis of a mental health problem or a learning or developmental disability that requires ongoing care A diagnosis of a mental health problem or a learning or developmental disability that requires ongoing care Yes No

Drug or alcohol dependency requiring treatment within the past 5 years Drug or alcohol dependency requiring treatment within the past 5 years Yes No

8- I have had back problems, hernia, ulcers and diabetes. 8- I have had back problems, hernia, ulcers and diabetes. Yes No

Recurring back problems over the past 6 months that limit my daily activity Recurring back problems over the past 6 months that limit my daily activity Yes No

Back or spine surgery within the last 12 months Back or spine surgery within the last 12 months Yes No

Diabetes, controlled by medication or diet, or gestational diabetes within the past 12 months Diabetes, controlled by medication or diet, or gestational diabetes within the past 12 months Yes No

An uncorrected hernia that limits my physical abilities An uncorrected hernia that limits my physical abilities Yes No

Active or untreated skin ulcers, chronic wounds or ulcer surgery within the past 6 months Active or untreated skin ulcers, chronic wounds or ulcer surgery within the past 6 months Yes No

9- I have had stomach or bowel problems, including recent diarrhea. 9- I have had stomach or bowel problems, including recent diarrhea. Yes No

Ostomy surgery (gastrostomy, colostomy or nephrostomy) without already having medical clearance for swimming or physical activities Ostomy surgery (gastrostomy, colostomy or nephrostomy) without already having medical clearance for swimming or physical activities Yes No

Dehydration requiring medical intervention within the last 7 days Dehydration requiring medical intervention within the last 7 days Yes No

Active or untreated gastric or intestinal ulcers, or surgical treatment of such ulcers within the past 6 months Active or untreated gastric or intestinal ulcers, or surgical treatment of such ulcers within the past 6 months Yes No

Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD) Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD) Yes No

Active or uncontrolled ulcerative colitis, or Crohn's disease Active or uncontrolled ulcerative colitis, or Crohn's disease Yes No

One bariatric surgery in the last 12 months One bariatric surgery in the last 12 months Yes No

10- I am taking prescription medication (except for contraceptives or antimalarials other than mefloquine (Lariam). 10- I am taking prescription medication (except for contraceptives or antimalarials other than mefloquine (Lariam). Yes No

First Name

Last Name

Birthdate

Date

Signature Signature of the participant (or, if a minor, participant's parent/guardian signature required) - Please press save before you submit the form SaveClear